Provider Demographics
NPI:1891724290
Name:TICKER, JONATHAN B (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:B
Last Name:TICKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2312
Mailing Address - Country:US
Mailing Address - Phone:516-798-0111
Mailing Address - Fax:516-798-0152
Practice Address - Street 1:660 BROADWAY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2312
Practice Address - Country:US
Practice Address - Phone:516-798-0111
Practice Address - Fax:516-798-0152
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180039207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1309558OtherCIGNA
NYAA47457OtherMDNY
NY35497526OtherMULTIPLAN
NYAS1634OtherOXFORD
NY1570938Medicaid
NY2000021570OtherRR MEDICARE
NY501030OtherGHI CBP
NY010180039NYOtherANTHEM
NY531270OtherAETNA US HEALTHCARE
NY5103229OtherAETNA PPO
NY1044724OtherFIRST HEALTH
NY1445199OtherUNITED
NY30293POtherHIP
NY180039SOtherHEALTHCARE PARTNERS
NYGHI PPOOther0501005
NY1C0831OtherHEALTHNET
NY60G781OtherBLUE CROSS BLUE SHIELD
NY68711OtherGHI HMO
NY1570938Medicaid